Pearls for practicing in the COVID-19 era

Results of an email survey sent to the Glaucoma Research Foundation (GRF) Ambassadors when most states were poised to ease coronavirus disease 2019 (COVID-19) restrictions showed that only three-fourths of the respondents had a plan in place for reopening their offices after stay-at-home orders were lifted.

Judging from write-in responses, whether or not the glaucoma specialists had developed strategies for returning to practice, they were interested in having colleagues share ideas for establishing safety and for optimizing practice efficiency and patient care delivery. They were also keen to receive post COVID-19 patient education and support materials from GRF.

These topics and more were addressed in a virtual GRF Ambassador Round Table on managing a glaucoma practice during COVID-19.

Related: COVID-19 safety challenges accelerating welcome changes​

Held on May 8, the discussion was moderated by Andrew Prince, MD, of Glaucoma Consultants of Greater New York & New Jersey, and Andrew Iwach, MD, of Glaucoma Center of San Francisco, and included input from several GRF Ambassadors that showed the clinicians were meeting the new challenges with different approaches; in part, these reflect variations in practice settings.

Recognizing that the pandemic situation will be evolving and that ideas about best practices are likely to change based on actual experience and changing circumstances, the group looked forward to reconvening to share their practical insights and take away new ideas.

Gearing up for in-office visits
Once stay-at-home orders were issued in California, only patients needing emergency care or a postoperative follow-up visit were being seen at the Glaucoma Center of San Francisco.

In planning for reopening, staff had to review charts to identify patients who should be given priority for an appointment, according to Iwach.

Patients who have an upcoming visit are being contacted by phone and are being screened for COVID-19 symptoms and informed about new processes in the office. The latter include requirements to wear a mask and enter alone unless they need to be accompanied by someone for language or other reasons.

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A screening station has been set up at the entrance to the building where patients are checked for fever and COVID-19 symptoms, asked to clean their hands with a hand sanitizer, and given a mask if they did not bring one.

Changes were made in the office, including removal of magazines, removal and rearrangement of furniture in the waiting area to create proper social distancing, and installation of plastic shields at the front desks.

Iwach and his associate, Terri-Diann Pickering, MD, identified restaurant supply companies and neighborhood hardware stores as good sources for acquiring protective equipment, including plastic shields, hand sanitizers, gloves, and masks.

Prince mentioned that individuals with an Amazon business account can register as a health care professional; then, they will be put on the top of a queue for getting supplies.

He also noted that in his practice, a solution containing 70% ethanol with hydrogen peroxide and glycerin that comes in large spray bottles is being used with paper towels for surface disinfection and offers a less expensive alternative to disinfectant wipes.

Related: Transitioning back to ophthalmic care during a pandemic​

Practices differed in their use of gloves for staff versus frequent hand washing and sanitizing, but all participants agreed that it was critical for patients to witness attention being given to hygiene.

Minimizing patient time in the office was a universal goal. In general, patients are undergoing necessary testing in the office. Oluwatosin Smith, MD, of Glaucoma Associates of Texas, said her practice is looking at establishing a dedicated center for glaucoma testing that would be separate from the rest of the clinic and might be opened for extended hours to meet the pent-up demand for services.

In-office physician–patient interaction is being limited. Patients are mostly being contacted following their visit once the provider has a chance to review the results from the diagnostic evaluations.

Depending on the need for follow-up, the results may be discussed over the phone or patients may be offered a telehealth or subsequent in-office visit.

Related: Capabilities of telemedicine for ophthalmologists during a pandemic: Part I​

IOP and visual field assessments
The participants agreed that home monitoring of IOP using a self-tonometer suffers from suboptimal accuracy.

A few have reduced the use of Goldmann applanation tonometry except when they are not able to get an accurate or reliable measurement with other tonometers that are noncontact or involve minimal time up close with the patient.

Davinder Grover, MD, MPH, of Glaucoma Associates of Texas, said that his group is using a noncontact device to measure corneal-compensated IOP in most patients, but a Tono-Pen is used to check IOP of postsurgical patients during the first month of follow-up.

Visual field testing presents a particular concern, given the special care that needs to be taken to avoid damaging the perimeter bowl. Participants felt that guidance on disinfection from the manufacturer lacked clarity, and many were exploring alternative methods for checking visual fields.

Both Grover and Iwach mentioned that their practices are pursuing other methods of perimetry that can be performed with a low risk to the patient, such as virtual reality goggle-type visual field testing.

Related: Putting to practice retina innovations amid a pandemic​ ​

Robert Feldman, MD, of the Robert Cizik Eye Clinic, Houston, Texas, said that visual field testing at his practice has been put on hold while the potential to use an ultraviolet (UV)-C lamp for sanitization is being investigated. He noted, however, that the perimeter manufacturer cautioned that UV-C light could damage the equipment.

Prince said that an air purifier was installed in his practice’s testing room.

“While there is no direct evidence yet that filtration works to reduce transmission of the novel coronavirus, it can be assumed from what we know of similar viruses that air purifiers might help in some situations,” he said.

Prince added that, theoretically, if an air purifier removes or reduces the viral load from the air, the potential for exposure is lessened.

“The novel coronavirus itself is 0.125 microns, but the droplets it travels in when people cough, talk, or breathe are around 1 μm,” he said. “That is a size easily captured by air purifiers with HEPA filters.”

Telemedicine
In the GRF Ambassador survey, the majority of respondents indicated that they had been using a telemedicine approach to some extent.

Ambassadors participating in the discussion agreed that telemedicine has limitations for following patients with glaucoma.

Certain patient queries can be handled by phone, and a video visit can be helpful for reviewing medication use or for checking whether a red eye in a surgically treated patient is worrisome.

Patients gain reassurance knowing that a physician has looked at their red eye, and the interaction itself can be a boost for patients who are socially isolated during the pandemic, Iwach said.

Related: The eyes offer conjunctival clue to COVID-19​

A novel model
Steven Vold, MD, in private practice at Vold Vision in Fayetteville, Arkansas, noted that because of the conducive physical setting of his office building, his practice created a “curbside clinic” where patients could be quickly checked for possible progression of their glaucoma.

“We know that compliance with glaucoma medication is an issue, and the concern when patients are not being seen is that some who have moderate-to-advanced glaucoma could be having asymptomatic worsening,” Vold said.

In Vold’s “clinic,” patients remain in their cars and go from station to station for a “visit” that is completed within 5 to 10 minutes.

After gathering insurance information and then a history, vision is tested with a device like that used at state motor vehicle departments, IOP is measured with a rebound tonometer, and anterior and posterior segment photographs are taken using a retinal camera through a 3-mm pupil.

Patients are contacted by a physician later in the day.

“I am not saying that it is ideal and I am not advocating this approach as a standard of care,” Vold said. “But I can say we have picked up numerous disc hemorrhages and elevated IOPs, and I think we have actually saved vision for some patients.”

Related: Emerging opportunities — and risks — with telehealth in a pandemic​

He added that the service has also been a practice builder. Patients who have seen its availability on the practice’s website have traveled as far as 1000 miles to get access to in-person care.

The encounter is charged as a telehealth visit. Before offering the service, the plan was reviewed with the Arkansas Department of Health and Arkansas State Medical Board.

Patient education
The GRF Ambassadors’ focus is on patient education, and some of the write-in responses on the GRF Ambassadors survey indicated interest in materials that would give patients confidence about the safety of in-office visits and inform them about new processes.

The physicians continue to do their part.

Vold said that his practice has created some videos with those goals in mind, and Smith noted that she is currently working with the Cure Glaucoma Foundation to develop patient information.

Thomas Brunner, president and CEO of GRF, said that GRF is also collaborating with this effort to inform and educate patients.

“Starting in early April with financial support from Industry, GRF began hosting a number of patient webinars and we recently launched a new video series that includes steps doctors are taking to ensure the safety of their patients.” Brunner added. “GRF can play a unique role in supporting both doctors and patients during this extraordinary time.”

Read more by Cheryl Guttman Krader

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Steven Vold, MD
e:svold24@gmail.com
Vold has no financial disclosures related to this content.